EmONC Toolkit 2016 i
ii EmONC Toolkit 2016
ACKNOWLEDGEMENTS The following individuals and institutions are acknowledged for their contributions to the development and conduct of the project and the preparation of this toolkit: the United States Agency for International Development (USAID) Kenya Family Health Team (Sheila Macharia and Lillian Mutea); USAID Kenya Strategic Information (Lize Ojowi and Washington Omwomo); Maternal and Child Survival Program (MCSP) Kenya (Lynn Kanyuuru and Gathari Ndirangu); University Research Company/ASSIST (Mwaniki Kivwanga and Prisca Muange); Liverpool School of Tropical Medicine; Kenya Ministry of Health Reproductive and Maternal Health Services Unit; the county health management teams of Baringo, Busia, Garissa, Kilifi, Kitui, Kwale, Machakos, Mandera, Meru, Mombasa, Murang a, Nairobi, Narok, Nyamira, Samburu, Isiolo, Tharaka Nithi, Trans Nzoia, Turkana, and Wajir counties; APHIAplus partners (Imarisha, Kamili, Nairobi-Coast, Rift Valley, and Western); and AMPATH PLUS. This toolkit was prepared based on methods and tools employed in the assessment, monitoring, and evaluation of a USAID-supported scale-up of emergency obstetric and newborn care conducted between 2013 and 2016 in 15 Kenyan counties with high maternal mortality. We thank the following MEASURE Evaluation PIMA staff who contributed to the development of the toolkit: Njeri Nyamu, Benter Owino, Ambrose Agweyu, Viola Rop, Yvonne Otieno, Judy Omumbo, and Geoffrey Lairumbi; Allison Schmale (MEASURE Evaluation, ICF International) for editing the toolkit; Debbie McGill (MEASURE Evaluation, University of North Carolina) for additional editing; and Denise Todloski (MEASURE Evaluation, University of North Carolina) for design and formatting. EmONC Toolkit 2016 iii
CONTENTS Acknowledgments... iii Abbreviations... v 1.0. Introduction... 1 1.1. Purpose of the Toolkit... 2 1.2. Toolkit Users... 3 1.3. Toolkit Organization... 3 2.0. Section I: EmONC M&E Indicators... 4 2.1 Structure Indicators... 4 2.2. Process Indicators... 6 3.0. Section II: Resource Materials... 8 3.1. Planning for M&E... 8 3.1.1. Selection of Target Facilities... 8 3.1.2. Participant Selection for Orientation Meetings... 8 3.1.3 Organizing the Orientation Meeting... 8 3.2 Dissemination of Results and Action Planning... 11 Appendix 1. Sample EmONC Orientation Meeting Program... 13 Appendix 2. Overview of EmONC Slide Presentation... 14 Appendix 3. Data Quality and Data Flow... 14 Appendix 4. Flow of EmONC M&E Data... 14 Appendix 5. EmONC/MNCH M&E Data Collection User Manual... 14 Appendix 6. EmONC/MNCH Health Facility Assessment Tool... 15 Appendix 7. EMonc Health Facility Assessment Excel Dashboard... 15 Appendix 8. EmONC Monthly Monitoring Tool... 15 Appendix 9. Mock EmONC Health Facility Assessment Tool: Participant... 16 Appendix 10. Mock EmONC Health Facility Assessment Tool: Facilitator... 16 Appendix 11. Sample Program for for Dissemination Meeting... 17 Appendix 12. Ministry of Health Kenya: Revised Partograph (2012)... 18 Appendix 13. Sample Health Facility Profile (for Illustrative Purposes Only)... 19 Appendix 14. Template for Documentation of Action Plans... 22 iv EmONC Toolkit 2016
ABBREVIATIONS AMTSL active management of third stage of labor APHIAplus AIDS, Population and Health Integrated Assistance BEmONC basic emergency obstetric and newborn care CEmONC comprehensive emergency obstetric and newborn care EmONC emergency obstetric and newborn care GoK Government of Kenya M&E monitoring and evaluation MCSP Maternal and Child Survival Program MDGs Millennium Development Goals MNCH maternal, newborn and child health MoH Ministry of Health RMHSU Reproductive and Maternal Health Services Unit, Ministry of Health UNFPA United Nations Population Fund UNICEF United Nations Children s Fund URC/ASSIST University Research Co., LLC Applying Science to Strengthen and Improve Systems USAID United States Agency for International Development WHO World Health Organization EmONC Toolkit 2016 v
1.0. INTRODUCTION The call to address the high rates of maternal and newborn mortality has received unprecedented support from governments and development partners over recent years. Increased investments in programs targeting maternal and newborn health have fueled demand for reliable and timely data to promote the rational allocation of resources where the burden of deaths is greatest. In Kenya, the Ministry of Health and county governments have committed to ensuring universal access to emergency obstetric and newborn care (EmONC). 1 The United States Agency for International Development (USAID) is a major partner of the Government of Kenya (GOK) in the effort to increase the national coverage of EmONC under its Ending Preventable Child and Maternal Deaths Strategy. EmONC is an integrated strategy developed by the World Health Organization (WHO), the United Nations Population Fund (UNFPA) and the United Nations Children s Fund (UNICEF) that aims to equip health facilities with the capacity to provide evidence-based, cost-effective interventions to attend to the leading causes of maternal and newborn mortality. 2 Two levels of care are recognized under this approach: basic (BEmONC) and comprehensive (CEmONC). BEmONC, provided at primary care facilities such as dispensaries and health centers, has seven essential medical interventions, known as signal functions. CEmONC, provided at hospitals, covers the seven BEmONC signal functions plus two more (Table 1). Table 1. BEmONC and CEmONC signal functions BEmONC Signal Functions (1) Administer parenteral antibiotics (2) Administer uterotonic drugs, such as parenteral oxytocin (3) Administer parenteral anticonvulsants, such as magnesium sulfate, for preeclampsia and eclampsia (4) Remove the placenta manually (5) Remove retained products of conception using methods such as manual vacuum aspirations or misoprostol for medical evacuation (6) Perform assisted vaginal delivery using methods such as vacuum extraction or forceps delivery (7) Perform basic neonatal resuscitation, such as with bag and mask CEmONC Signal Functions Perform all seven components of BEmONC plus (8) Perform Caesarean section (9) Perform blood transfusion This toolkit is the result of collaborative work by MEASURE Evaluation PIMA, USAID, the Maternal and Child Survival Program (MCSP), University Research Company/ASSIST, APHIAplus, AMPATH PLUS implementing partners, the Ministry of Health (MOH), and county health management teams 1 Ministry of Health (MOH), Government of Kenya. (2009). National reproductive health strategy 2009 2015. Nairobi, Kenya: MOH. 2 World Health Organization (WHO); United Nations Population Fund; United Nations Children s Fund; Averting Maternal Death and Disability, Columbia University Mailman School of Public Health. (2009). Monitoring emergency obstetric care: A handbook. Geneva, Switzerland: World Health Organization. EmONC Toolkit 2016 1
targeted in the initial phase of the national scale-up of BEmONC. 3 The toolkit incorporates experiences from the first two phases of the national EmONC scale-up exercise launched in July 2013. The national scale-up of the monitoring and evaluation (M&E) of EmONC was based on the theoretical framework drawn from the Donabedian model, which categorizes quality of care in three interlinked unidirectional dimensions: (1) structure, (2) process, and (3) outcome. 4 An example of this interlinked framework is how changes in structure-related items, such as commodities, buildings, equipment, and guidelines, directly influence the process of care, such as patient diagnosis and treatment. In turn, patient diagnosis and treatment determine outcomes, such as morbidity and mortality. Through periodic assessments of health facility capacity to provide the EmONC signal functions, it is possible to infer the progressive capabilities to reduce maternal and newborn mortality. Figure 1 illustrates this framework. Figure 1. Theoretical framework for the evaluation of the scale-up of EmONC in Kenya 1.1. Purpose of the Toolkit The GOK and national and county implementing partners require timely quality data to develop appropriate targeted decisions based on needs. This toolkit was developed to produce data through coordinated periodic reporting of key interventions for maternal and newborn survival at the health facility, subcounty, county, and national levels. The materials in this package provide instruction in data collection on a set of harmonized indicators that are measurable at all health facilities and can be interpreted nationally and globally. The toolkit provides simple dashboards that can be used for data management, analysis, and reporting in counties, and subsequently for effective dissemination of M&E results that can be used to develop action plans. 3 The participating counties are Baringo, Busia, Kitui, Machakos, Mandera, Meru, Murang a, Narok, Nyamira, Samburu, Tharaka Nithi, Trans Nzoia, and Wajir. 4 Donabedian, A. (1988). The quality of care. How can it be assessed? Journal of the American Medical Association, 260 (12):1743 1748. 2 EmONC Toolkit 2016
1. 2. Toolkit Users This toolkit is intended primarily for county M&E officers, reproductive health coordinators, and other members of county health management teams and partners involved in implementing EmONC. It is also useful for national M&E officers and other professionals and donors who are involved in maternal and newborn health programs. 1.3. Toolkit Organization The toolkit is divided in two sections. Section I define the indicators used for monitoring and evaluating EmONC interventions and describes their relationship with the major causes of maternal and newborn deaths.. Two types of indicators are presented; (a) those used for assessing the structure, such as equipment, staffing, and consumables; and (b) indicators for assessing the process of care, such as documenting appropriate practices for providing EmONC. Section II lists resources for planning M&E, methods for conducting M&E, and outlets for disseminating the findings. This section includes training materials, data collection tools, analysis dashboard templates, and templates for health facility profiles. EmONC Toolkit 2016 3
2.0. SECTION I: EmONC M&E INDICATORS The leading causes of maternal death are postpartum hemorrhage (PPH), hypertension, infections, obstructed labor, and complications arising from abortion. These causes account for over two-thirds of the estimated 289,000 annual global mortalities related to pregnancy and childbirth. 5 About three-quarters of neonatal deaths are attributable to infections, preterm birth, and intrapartum complications. 6 These top causes of maternal and newborn mortality are all largely preventable through the effective use of highly cost-effective interventions in EmONC. 2.1 Structure Indicators Each signal function provides specific interventions to treat the life-threatening complication. Table 2 summarizes the nine CEmONC signal functions and the major causes of maternal and newborn mortality, the indicators, and the main conditions targeted. 5 Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R.,... Lozano, R. (2014). Global, regional, and national levels and causes of maternal mortality during 1990 2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384 (9947): 980 1004. Retrieved from http://www.thelancet.com/journals/lancet/article/piis0140-6736(14)60696-6/abstract 6 Wang, H., Liddell, C. A., Coates, M. M., Mooney, M. D., Levitz, C. E., Schumacher, A. E.,.. Murray, C. J. L. (2014). Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990 2013: A systematic analysis for the Global Burden of Disease Study 2013. The Lancet, 384 (9947): 957 979. Retrieved from http://www.thelancet.com/journals/lancet/article/piis0140-6736(14)60497-9/abstract 4 EmONC Toolkit 2016
Table 2. EmONC M&E structure indicators Basic Signal Functions Indicators Main Conditions Targeted (1) Administer parenteral antibiotics Availability of: injectable penicillin and gentamicin and metronidazole OR ceftriaxone and metronidazole Puerperal sepsis (2) Administer uterotonic drugs Availability of parenteral oxytocin Postpartum hemorrhage (3) Administer parenteral anticonvulsants for severe preeclampsia and eclampsia Availability of magnesium sulfate Preeclampsia/eclampsia (4) Manually remove the placenta Availability of sterile elbow-length gloves Postpartum hemorrhage, puerperal sepsis (5) Remove retained products of conception Availability of manual vacuum aspiration (MVA) kit OR misoprostol for medical evacuation Abortion 6) Perform assisted vaginal delivery Availability of vacuum extractor Obstructed labor (7) Perform basic neonatal resuscitation Availability of pediatric bag valve mask device Comprehensive Signal Functions Perinatal asphyxia (8) Perform surgery (e.g. Caesarean delivery) Availability of Caesarean delivery set Obstructed labor, preeclampsia/ eclampsia, obstetric hemorrhage, perinatal asphyxia (9) Perform blood transfusion Availability of blood transfusion sets Obstetric hemorrhage Additional indicators Training of health workers on EmONC Availability of EmONC clinical guidelines All All EmONC Toolkit 2016 5
The EmONC Health Facility Assessment Tool (Appendix 6) also collects information on the availability of equipment and consumables required for general maternal newborn and child health services, including equipment for provision of emergency care, basic surgical equipment, and equipment for routine clinical assessment. 2.2. Process Indicators While structure-related indicators represent the basic elements for the provision of quality care, their availability does not necessarily reflect appropriate use. Examination of this dimension of care requires the assessment of the process of care. Measures of process of care are, however, often difficult to define and, unless observed directly, are greatly affected by the quality of documentation a major limitation in low- resource settings. Table 3 displays a set of indicators selected for the assessment of process of care of EmONC and the main causes of maternal and newborn mortality targeted. 6 EmONC Toolkit 2016
Table 3. EmONC M&E process indicators EmONC Process indicator Indicator Assessed Main Conditions Targeted 1 Administration of oxytocin within 1 minute of delivery 2 Appropriate use of partograph 3 Appropriate monitoring of maternal blood pressure 4 Appropriate newborn resuscitation Proportion (%) of deliveries at the health facility for which oxytocin was delivered within 1 minute of delivery Proportion (%) of deliveries at the health facility for which partograph was filled in appropriately for monitoring of fetal heart rate and maternal condition and reporting the outcome of labor Proportion (%) of deliveries at the health facility for which blood pressure was monitored at least every 4 hours during labor Proportion (%) of newborns at risk of perinatal asphyxia documented to have received appropriate resuscitation Risk of perinatal asphyxia defined by: 5 minute Apgar score <7 or irregular shallow breathing or pulse rate <60 beats/ minute Postpartum hemorrhage Obstructed labor, preeclampsia/ eclampsia perinatal asphyxia, postpartum hemorrhage Preeclampsia/eclampsia Perinatal asphyxia 5 Maternal death audits Proportion (%) of sampled maternal deaths for which mortality audit was conducted 6 Perinatal death audits Proportion (%) of total perinatal deaths reported and total number audited All All EmONC Toolkit 2016 7
3.0. SECTION II: RESOURCE MATERIALS In this section, resources required for each phase of the M&E planning, implementation, and dissemination phases of the M&E cycle are provided. 3.1. Planning for M&E The success of the M&E exercise is dependent on adequate preparation. Early identification of relevant stakeholders and their appropriate engagement allows for the incorporation of diverse views and preferences in the approach to conducting the exercise and timely modification where challenges are anticipated. 3.1.1. Selection of Target Facilities Health facilities are the primary units of the assessment. The approach to selection of target health facilities must therefore aim toward ensuring representativeness of the facilities in the region. Health facilities that attend to large volumes of clients and those with a high burden of maternal and newborn mortality should be prioritized during the selection process. However, both Tier 2 (health centers and dispensaries) and Tiers 3 and 4 (subcounty and county hospitals) should be included in the selection to provide data on the availability of BEmONC and CEmONC services, respectively. Attempt to ensure that the facilities selected are distributed across all regions of the county. Select health facilities that have been included in previous assessments before considering new facilities, to allow for the comparison of performance over time. Upon identification of potential target health facilities, formal communication of the intended exercise needs to be delivered to the respective health facility administrators through the county health management teams. It is important to receive feedback from the health facilities confirming participation in the exercise and to take note of issues raised that may present challenges during the assessments. 3.1.2. Participant Selection for Orientation Meetings The orientation meeting is an opportunity to communicate the purpose, objectives, approach, and expected outputs of the EmONC assessments to a diverse audience of stakeholders at a single venue. Effective stakeholder engagement is critical for maximizing the impact of the data generated for decision making and resource allocation. The value of data is enhanced when stakeholders feel included during the design, implementation, and reporting of the M&E activity. A significant part of the orientation meeting focuses on providing the participants with a detailed understanding of the M&E tools and their appropriate use. It is therefore important for the participants at the meeting to include people who will be responsible for the collection and reporting of data from the assessments at the health facilities. A target audience of 30 participants is appropriate. Invitations should be issued to members of the county and subcounty administration, including the county health executive and the county health director, health facility in-charges, maternity in-charges at the participating health facilities, health records information officers, and county M&E officers. Implementing partners conducting reproductive maternal and newborn health programs within the county are important stakeholders whose attendance is required to ensure coordination and harmony across ongoing and planned activities within the county. Timely delivery of invitations and follow-up communication to confirm attendance are essential to ensure participation by the target audience. Invited participants who are unable to attend the meeting should be requested to suggest appropriate alternative representatives. 3.1.3 Organizing the Orientation Meeting The orientation meeting should be scheduled to take place over one full day. Select a day that does not conflict with major activities that are likely to involve key participants. Planners need to account for the duration of travel to and from the destination of the meeting that can, in some regions, take up to one day. 8 EmONC Toolkit 2016
The key objectives of the meeting are: 1. To describe the basis for and ensure uniform understanding of the EmONC scale-up exercise to all relevant stakeholders within the county, including county health officials, health facility administrators, health records information officers, implementation partners, and donors involved in maternal, newborn, and child health activities 2. To disseminate the findings of previous EmONC assessments at both national and county levels and to summarize progress toward achieving existing targets 3. To communicate the approach to conducting the health facility assessments, emphasizing the importance of data quality and timeliness of reporting 4. To orient the participants on the structure of the M&E tools and provide practical demonstrations of the appropriate approach to completion of the tools Venue of the Meeting A suitable venue needs to be identified and reserved at least one month ahead of the meeting. Characteristics of a suitable venue include central location, ample security, capacity to host all participants, and proximity to accommodation facilities for individuals traveling long distances. Aspects of the environment where the meeting is conducted, such as lighting, acoustics, ventilation, arrangement of furniture, seating capacity, stationery, availability of restrooms, and access to electricity sources to power equipment, such as liquid crystal display projectors and laptops, are all essential considerations in the selection of a venue for the meeting. Catering services need to be negotiated in advance, either internally with the management of the host venue or externally, and should accommodate varying dietary preferences of the participants. These factors create an optimal setting for effective communication and can have a major effect on the interpretation of the meeting by the audience. Attributes of a suitable venue for the orientation meeting 1. Central location Facilitators 2. Ample security A good facilitator will have a sound understanding of the 3. Capacity to host all participants material to be presented. The facilitator should affirm 4. Proximity to lodging her authority to be a mentor for the participants as early as possible during the presentation, by describing her qualifications and experience. The facilitator should make an effort to ensure that all presentations are relevant, meaningful, and engaging. Active participation should be encouraged, and presentations should be carefully moderated to ensure that the views aired are sensitive to and reflect the diversity of the audience. The facilitator must prepare adequately, to ensure that the content can be delivered clearly and within the allocated time. Program for the Orientation Meeting The program should be prepared ahead of the meeting and distributed to the prospective participants along with the invitations to attend the meeting. This ensures that participants are aware of the start and finish times and specific sessions scheduled. Printed versions should be available for participants as they register at the beginning of the meeting. Each activity on the program should have a time assigned. Appendix 1 offers a sample program for the orientation meeting. (a) Registration All participants should be requested to register upon arrival at the meeting venue. The registration form should include details of the participants names, designation, institutional affiliation, telephone, and email contacts. Each person should receive a nametag at the registration desk. (b) Introduction The main facilitator should welcome the participants to the meeting and introduce himself to the participants. Allow the participants to briefly introduce themselves if time permits. The chief guest (if EmONC Toolkit 2016 9
present) or a representative of the county administration should be invited to provide opening remarks. It is useful to spend a few minutes at the beginning of the meeting going over the agenda and expectations of the participants during each session. Assign a timekeeper to ensure that each speaker observes the allocated time. (c) Overview of EmONC Introduce the session and state the objectives: 1. To review the burden of maternal and newborn morbidity and mortality 2. To describe the basis for EmONC and the signal functions The presentation should begin with a summary of the trends and current burden of maternal and newborn mortality at the global, national, and (if possible) county levels. A definition of EmONC and the signal functions should then be provided. Each signal function should be explained with an emphasis on the respective cause of maternal mortality targeted. Questions from the audience should be invited and the presentation should end with a short summary. Presentation slides for this session are provided in Appendix 2 [External link]. (d) Data quality and data flow presentations Introduce the session and state the objectives: 1. To describe the importance of collecting quality data 2. To discuss measures for ensuring data quality during the assessments Practical examples can be given to illustrate the principles described. A guided discussion on the importance of observing the principles presented in the lecture should be held at the end of the presentation if time permits. Invite questions before summarizing the learning objectives for the session. The PowerPoint slides for this session are provided in Appendix 3 [External link]. Flow of EmONC M&E Data The flow of data from the assessments of the health facilities to the generation of reports for dissemination will be displayed. Each step should be described in detail and participants should be encouraged to seek clarification where necessary. The PowerPoint slide for this presentation is provided in Appendix 4 [External Link]. (e) Introduction to the M&E tools Introduce participants to the session and state the objectives: 1. To illustrate the organization of the M&E tools 2. To discuss the standard operating procedures for data collection using the M&E tools Provide the participants with a general description of the tool, by stating that it consists of 15 sections that must be completed. Proceed to describe the M&E tools listed below in detail with the aid of the data collection user manual provided in Appendix 5 [External link]. EmONC/Maternal, Newborn, and Child Health Facility Assessment Tool. Appendix 6 [External link] EmONC Health Facility Assessment Excel Dashboard. Appendix 7 [External link] EmONC Monthly Monitoring Tool. Appendix 8 [External link] Invite questions from the participants and terminate the session after providing a summary of the session linked to the objectives stated above. (f) Practical session using revised data collection tool Introduce participants to the session and state the objectives: 10 EmONC Toolkit 2016
1. To demonstrate the use of the EmONC assessment tool 2. To identify potential errors during data collection This session will require an adequate number of printed copies of the participants version of the Mock EmONC Health Facility Assessment Tool described in Appendix 9 [External link] and one copy of the facilitator s version of the Mock EmONC Health Facility Assessment Tool described in Appendix 10 [External link]. After distributing copies of the participants version of the tool, instruct the participants to use training provided in the preceding session to identify errors in the mock tool. This exercise should take approximately 10 minutes. Initiate a group discussion on the errors identified and their possible solutions. Encourage active participation by those who are likely to be involved in data collection. Invite questions from the participants relating to the exercise. Summarize the learning objectives once again and terminate the session. 3.2 Dissemination of Results and Action Planning Dissemination events bring stakeholders together to share the findings and experiences of the implementation exercise. Dissemination and action planning represent the final activities in the M&E cycle and can be powerful platforms for advocacy. When selecting participants for the dissemination event, ensure that all stakeholders are represented (see Selecting Participants for Orientation Meetings above). As described in the section on planning for the orientation meeting, timely distribution of invitations is crucial for the success of the event. A sample agenda of the orientation meeting is provided in Appendix 11. While planning the meeting, consider the following qualities of effective communication: 1. Understanding the needs of the target audience The primary aim of a dissemination meeting is to communicate. While preparing the content for the meeting, bear in mind that different members of the audience have different expectations, expertise, and language preferences. Table 4 illustrates the varying expectations of a hypothetical panel of stakeholders attending a dissemination meeting. Table 4: Stakeholder expectations of dissemination events Stakeholder Funding organization Expected Information Are the goals of the project being met? Hospital staff Partners County government National government How did we perform? What changes in our day-to-day work environment do I expect? Did we achieve our objectives? What new interventions can we launch in the next phase of implementation? How do the achievements of this intervention compare with the county targets? How do the achievements of this intervention compare with the national targets? EmONC Toolkit 2016 11
2. Focusing on goals The dissemination meeting should focus on informing and motivating the audience rather than simply reporting the findings. The facilitator must aim to contextualize the information to help the audience understand the importance of the results, and begin to consider the potential actions that should be taken in light of the findings. 3. Encouraging dialogue There is evidence to suggest that dissemination strategies that result in new ideas and actions tend to be based on relationships and dialogue, rather than unidirectional flow of information. To encourage the target audience to understand and use the findings of the evaluation, encourage controlled discussions while sharing the findings. 4. Preparing a clear and focused presentation The presentation should be concise and to the point. Aim to limit the number of slides highlighting the main results to 15. While presenting, spend more time on highlighting the key findings and recommendations. Be sure to define any specialist terminology and adopt an attractive and readable format (use no more than five bullet points per slide with a minimum font size of 28 for text). Break the monotony of large blocks of text by incorporating relevant images and graphs. An example of a slide deck that could be presented at a dissemination meeting is in Appendix 12 [External link] Action Planning The process of action planning should take place after the presentation of findings of the results of the evaluation. Printed copies of facility profiles (a sample of one appears in Appendix 13) should be distributed to the participants to provide additional details on the performance of individual health facilities included in the assessment. Depending on the organization of the venue, participants may be divided into heterogeneous groups of up to five people to deliberate on possible actions for the subsequent phase of implementation based on the results presented. A standard format should be adopted for documenting action plans. (A generic template is provided in Appendix 14.) The small groups should then reconvene and share their discussions with the other participants. A rapporteur should be appointed from among the members of the audience to document the discussions and compile minutes of the meeting and a consolidated action plan for sharing with the stakeholders, including those who are not in attendance. 12 EmONC Toolkit 2016
EmONC Toolkit Appendixes APPENDIX 1. SAMPLE EMONC ORIENTATION MEETING PROGRAM EmONC Health Facility Assessment County Orientation Programme Time Activity Facilitator 0800-0830 Registration MOH 0830-0900 Introductions MOH 0930 1000 Overview of EmONC MOH/RH Coordinator 0900 0930 County MNH indicators MOH 1030-1100 Tea 1100-11.30 Ensuring quality data for M&E Partner/MOH M&E staff 1130 1145 Flow of assessment data Partner/MOH M&E staff 1145-1245 Data collection tools - Description of sections and procedure for completion Measure Evaluation PIMA/Lead partner 1245-1345 Lunch 1345-1600 Practical session using revised data collection tools Measure Evaluation PIM /Lead partner 1600-1615 Break 1615-1700 Feedback, next steps MOH/Lead partner EmONC Toolkit 2016 13
EmONC Toolkit Appendix 2 APPENDIX 2. OVERVIEW OF EMONC SLIDE PRESENTATION Maternal and newborn mortality are major public health challenges in many low-income countries. Emergency Obstetric and Newborn Care (EmONC) is an integrated package of care that aims to equip health facilities with the capacity to provide evidence-based, cost-effective interventions to attend to the leading causes of maternal and newborn mortality. Two levels of care are recognized under this approach: basic (BEmONC) and comprehensive (CEmONC). BEmONC, provided at primary care facilities such as dispensaries and health centers, has seven essential medical interventions, known as signal functions. CEmONC, provided at hospitals, covers the seven BEmONC signal functions plus two more. This appendix is linked to a PowerPoint deck that provides a summary of the current estimates of maternal and newborn mortality by cause and the relevance of the EmONC strategy in tackling these causes, focusing on the signal functions. APPENDIX 3. DATA QUALITY FOR MONITORING AND EVLAUATION The availability of high quality data underpins the theoretical framework of the EmONC Scale-up intervention for which this toolkit has been designed. By providing data on performance across successive assessments at national, county, subcounty and health facility levels, decision makers are able to benchmark their capacities and prioritize identified needs. Experience from initial phase of the scale-up indicated the need for focused communication on the importance of data quality during orientation and dissemination exercises. The PowerPoint deck linked to this appendix outlines the generic elements of quality data to provide a basis for a guided discussion of the relevance data quality in the monitoring and evaluation of the national EmONC scale-up. APPENDIX 4. FLOW OF EmONC MONITORING AND EVLAUATION DATA Data for M&E of the national EmONC scale-up that are shared during orientation and dissemination meetings and other forums undergo a series of checks from the point of collection at the health facilities through the generation and dissemination of reports. This process ensures that the findings presented are an accurate reflection of the situation at each of the health facilities assessed. The PowerPoint slide linked to this appendix illustrates the flow of data from the point of collection at the health facility to the development of a final report. APPENDIX 5. EmONC/MNCH M&E DATA COLLECTION USER MANUAL High-quality data are an important resource for the health sector in planning, managing, delivering, and monitoring high-quality, safe, and reliable health care. The purpose of this manual is to aid the teams conducting M&E of the national EmONC scale-up exercise at health facilities through the process of data collection, to ensure uniform interpretation of data sources, indicators, and methods across locations and over time. The manual is also required during training exercises in preparation for M&E activities. It is divided into sections A, B, and C that provide directions for the use of the monthly assessment tool, Excel dashboards, and the monthly monitoring tool, respectively. The complete manual is linked here. 14 EmONC Toolkit 2016
APPENDIX 6. EmONC Health Facility Assessment Tool Data collection shall be undertaken by a designated enumerator for each facility using the EmONC Health Facility Assessment Tool. The methods are interviews, visual inspection, and data abstraction from facility records, as guided by instructions in the tool. The Health Facility Assessment Tool comprises 15 parts that should all be completed. The tool is linked here: EmONC Health Facility Assessment Tool. APPENDIX 7. EmONC HEALTH FACILITY ASSESSMENT EXCEL DASHBOARD The Excel dashboard is used to automatically generate basic graphs summarizing performance of the EmONC signal functions at the county and subcounty levels. Data from all health facilities in the county that are collected using the tool and that are included in the assessment will be entered by the respective implementing partner/county M&E teams in a standard Excel template specific for the region. The document consists of two worksheets: The first tab is titled BEmONC Data Collection. Use this worksheet to enter the data collected in the health facility assessment tools. The second tab is the Data Summaries & Dashboards sheet, which generates dashboards automatically. It is not to be completed or changed. The dashboard results can be used by the partner/county teams to disseminate EmONC assessment results and conduct action planning. A sample dashboard is linked here: EmONC Health Facility Assessment Excel Dashboard. APPENDIX 8. EmONC MONTHLY MONITORING TOOL Completion of the monthly monitoring tool is recommended for each facility. Data for this exercise may be collected through scheduled physical visits to health facilities or through telephone interviews with the maternity in-charges or other senior staff stationed in the maternity and newborn departments of the participating health facilities. The structure of the monthly monitoring tool is similar to the health facility assessment tool. It comprises three sections in a single Excel document. 1. Instructions: This section is found on the first tab of the Excel document. It provides direction on the approach to completion of the structure-related signal function (shaded green) and process of care (shaded brown) sections of the monitoring tool. This section of the tool can be printed for convenience when data are being collected. 2. Monthly monitoring tool: A summary sheet with a row for each facility details performance across the nine EmONC signal functions and four process of care indicators. A sampling strategy similar to that used in the Health Facility Assessment Tool described above is used (refer to Section 14.0) that aims to select up to 35 records for deliveries conducted at each health facility. This section of the tool should be printed and copied to accommodate the total number of health facilities in the county. 3. County summary: The subsequent tabs labelled County Summary are completed using data collected in the printed and filled monthly monitoring tools located in the second tab of the Excel spreadsheet and described in the previous paragraph. This section provides monthly summaries of performance for a year across the EmONC signal functions and process of care indicators for the participating health facilities. Sections of this spreadsheet that display computed summaries of performance are locked for editing and cannot be modified directly. The tool is linked here: EmONC Monthly Monitoring Tool. EmONC Toolkit 2016 15
APPENDIX 9. MOCK EmONC HEALTH FACILITY ASSESSMENT TOOL: PARTICIPANT Use the Mock EmONC Health Facility Assessment Tool to train participants on how to complete the facility assessment tool appropriately. Download and print an adequate number of copies of the participants version of the document through this link. APPENDIX 10. MOCK EmONC HEALTH FACILITY ASSESSMENT TOOL: FACILITATOR Use the Mock EmONC Health Facility Assessment Tool for facilitators to train participants on how to complete the facility assessment tool appropriately. Download and print a copy for each facilitator through this link. 16 EmONC Toolkit 2016
APPENDIX 11. SAMPLE PROGRAM FOR DISSEMINATION MEETING Program for EmONC Health Facility Assessment County Dissemination and Action Planning Meeting Time Activity Facilitator 0800-0830 Registration MOH 0830-0900 Introductions and outline of objectives MOH 0930 1015 Presentation of assessment results: county and facility profiles MOH/RH coordinator/ M&E staff 1015 1100 Plenary discussions on assessment results MOH/partner 1100-1130 Tea 1130-13.30 Action planning MOH/partner 1330 1430 Lunch 1430-1530 Action planning MOH/partner 1530-1630 Plenary: Feedback on facility action plans MOH/partner 1630-1700 Next steps and close MOH/partner EmONC Toolkit 2016 17
APPENDIX 12. SAMPLE PRESENTATION FOR DISSEMINATION MEETING The dissemination meeting is a unique opportunity to communicate the findings and experiences of the implementation exercise to multiple stakeholders at a single event. It is the final activity in the M&E cycle. The main presentation summarizing the findings of the assessment should focus on informing and motivating the audience rather than simply reporting the findings. The facilitator must aim to contextualize the information to help the audience understand the importance of the results, and begin to consider the potential actions that should be taken in light of the findings. The PowerPoint deck linked here is an example of an EmONC assessment dissemination presentation. It should be modified to with relevant content. 18 EmONC Toolkit 2016
APPENDIX 13. SAMPLE HEALTH FACILITY PROFILE (FOR ILLUSTRATIVE PURPOSES ONLY) County EmONC Health Facility Profile Phase II The facility profiles provide summaries of data collected on the availability of selected items required for the provision of the seven BEmONC signal functions from each facility surveyed in the county. BEmONC Signal Function (SF) Item Assessed 1 Administration of parenteral antibiotics Availability of crystalline penicillin / ampicillin + gentamicin + metronidazole 2 Administration of uterotonic drugs Availability of oxytocin 3 Administration of parenteral anticonvulsants Availability of magnesium sulphate 4 Manual removal placenta Availability of elbow-length gloves 5 Removal of retained products Availability of manual vacuum aspiration kits 6 Performance of assisted vaginal delivery Availability of vacuum extractor for assisted vaginal delivery 7 Performance of basic neonatal resuscitation Availability of neonatal bag valve mask device Guidelines Training National Guidelines for Quality Obstetrics and Perinatal Care Proportion (%) of health workers working in maternity/newborn departments trained on the harmonized BEmONC training course in the preceding 12 months EmONC Toolkit 2016 19
Sample Facility Profile Muranga County: EmONC Signal Functions SF Signal Function 1 - Able to Perform 0 Unable to Perform M Missing data! Error Facility Name Facility level Injectable antibiotics Oxytocin Magnesium sulphate Elbowlength gloves MVA kit / misoprostol Vacuum extractor Pediatric Ambubag C- section set Blood transfusion set Makuyu HC HC/ Disp 0 1 1 0 1 1 1 0 0 Sabasaba HC HC/ Disp 0 1 1 0 1 1 0 0 0 Maragua Ridge HC HC/ Disp 1 1 1 1 1 1 1 0 0 Kandara SCH Hospital 1 1 1 1 1 0 1 0 0 Muran'ga CRH Hospital 1 1 1 1 1 1 1 1 1 Kangema SCH Hospital 1 1 1 1 1 1 1 0 0 Kigumo SCH Hospital 1 1 1 0 1 1 1 0 1 Muriranjas SCH Hospital 1 1 1 1 1 1 1 0 1 Maragua DH Hospital 1 1 1 1 1 1 1 1 1 20 EmONC Toolkit 2016
Sample Facility Profiles: EmONC Process of Care Facility Name Level HCW trained on BEmONC (%) Oxytocin use for AMTSL (%) Appropriate partograph use (%) BP monitoring in labour (%) Newborn resuscitation (%) KMC for low birth weight neonates (%) Audited maternal deaths (%) Audited perinatal deaths (%) Makuyu HC HC/ Disp 27 55 64 57 0 NA NA NA Sabasaba HC HC/ Disp 0 16 39 16 NA NA NA NA Maragua Ridge HC HC/ Disp 57 71 90 90 0 NA NA NA Kandara SCH Hospital 0 45 54 30 100 NA NA NA Muran'ga CRH Hospital 0 100 77 77 67 NA 100 NA Kangema SCH Hospital 60 100 79 79 100 NA NA NA Kigumo SCH Hospital 0 52 33 2 NA NA NA NA Muriranjas SCH Hospital 0 100 6 6 100 NA 100 NA Maragua DH Hospital 39 60 38 36 20 NA 100 NA NA: No observations EmONC Toolkit 2016 21
APPENDIX 14. TEMPLATE FOR DOCUMENTATION OF ACTION PLANS EmONC Health Facility Assessment Template for County Action Plan Development Assessment Area Gaps identified Proposed Solutions IV antibiotics (SF 1) Oxytocin (SF 2) Magnesium sulphate (SF 3) Elbow-length gloves (SF 4) MVA kits / misoprostol (SF 5) Vacuum extractors (SF 6) Neonatal ambu bags (SF 7) Caesarean section sets (SF 8) Blood transfusion sets (SF 9) EmONC training Guidelines Staffing Equipment Hygiene and sanitation Power supply Linking MPDSR to EmONC Process indicator 1 Process indicator 2 Process indicator 3 Process indicator 4 Quality improvement Progress Target Timeframe Responsible Person Resources 22 EmONC Toolkit 2016
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